Improving Health Care Quality Through Electronic Health Records

In this post, I would like to share a video I watched recently which examines the use of Electronic Health Records (EHRs) to improve quality of healthcare. The video- posted by HRSA- is fairly long but also very informative. Enjoy it.

Can Information Technology Improve Readmission Rates?

Source: Vital Partners

Many factors have been found to be associated with readmissions according to a study done by Allison Nudge and colleagues in Australia.  The authors showed a correlation between readmissions rate and factors like co-morbidities, nutritional status and mood  of the patients. They studied patients with chronic conditions who had two or more admissions in six months. The rate of readmissions is an important issue for hospital administrators and policy makers because of their relationship to increasing costs, especially in health systems that use the DRG (Diagnosis Related Group) payment system like the United States.

It is within this backdrop that I discuss the ability of information technology to help solve or at least, reduce this problem. Carol Everhart, in an article published online in Pharmacy Choice, opined that hospitals should pay attention to the particular reasons why individual patients are returning to the hospital after being discharged home and not focus solely on aggregated hospital data.

How can hospitals do this? It is obvious as shown in Nudge's paper, that one readmission drastically increases the risk for repeat readmissions as well as other factors she described. Granted, there is not much that can be done by physicians without electronic medical records and so, my suggestions are going to be based on situations where there are clinical decision making tools like CDSS (for an understanding of this, see my previous posts).

Is it possible to write a program such that the presence of these risk factors for readmissions are coded in the electronic medical records and a warning system is put in place such that the physician in charge is able to activate an anti-readmissions protocol which can help reduce the likelihood of another readmission? By all indications, this is possible and I am almost sure that this is been put in place somewhere. If you have an idea of where this occurs, please let me know.

We would do well to note that many factors that predispose to readmissions are not known at the time of discharge and consequently, cannot be predicted. However, most of them are known and the patient can benefit from these interventions which can also help the hospital save costs. Will these technological innovations be useful for preventing readmissions that are due to nutritional problems or mood/ psychological imbalances as discussed by Nudge et. al? I guess we just have to keep our fingers crossed.

In my next post, I will report such technological innovations and where they are being put into use.

Readmissions is a very exciting area that I look forward to exploring going forward.

Technology to Improve Patients' Adherence to Medication

I will like to share with you as promised, a technology based initiative that I believe will help improve patient adherence. This program will involve a combination of periodic text messages or e-mails informing patients of the time to take their medication coupled with an alarm fitted on the medication packet that can only be stopped after the patient takes the pill.

Description: the pills will be in an electronic container that will beep like an alarm clock at the time the drug is due to be taken. The alarm only stops when the pill is removed. At the same time, a text message or email will be sent daily to remind the patient. For multiple pills, a computer program can be used.

The initiative has two potential disadvantages: one is that the patient can develop alert fatigue, that is, gets “numbed” to the alerts and might develop an aversion to the system. This can only be solved by a patient education program which must run concurrently. The other is that the system does not actually tell if the patient takes the medication, it only tells if the pill was removed.

Options: The patient will be placed in the program by default but can only opt-out if the physician decides that the patient is not at risk of default, evidenced by writing a letter of undertaking on behalf of the patient.

The mechanism involves active choice by the patient. The patient can only opt out after showing a record of adherence for a period of time, say 3 months after which the doctor can vouch for him/her.

Consequences of default were described by Martin et al. (2005) and include development of worse symptoms, progression of disease to more fatal stages, higher cost of treatment, increased risk of infecting others, time wasting seeking treatment, inefficiency of health systems etc

The program does not preserve the choice of the patient to a large extent. However, with the concurrent patient education program, the patient can be made to understand that the risk of default are too great and that if he complies, he does not have to get an alarm ring and he can be out of the program after 3 months if he complies. The program would be cost effective in that it would save the health system from bearing the cost burden of non-adherence

Reference

Leslie R Martin, Summer L Williams, Kelly B Haskard  and M Robin DiMatteo (2005). The challenge of patient adherence; Journal of Clinical Risk Management, September; 1(3): 189–199.

Future of IT in Hospital Care

I asked a question in my last post, “What will the future of healthcare look like?” I could also ask that question in another way: “How will information technology impact the way we practice medicine and interact with hospitals? I will attempt to answer the question in different domains:

Source: nyp.org

1.     Disease Diagnosis:  The emphasis on disease management might change in the next 50 years to the development of “diagnostic supercomputers” that can scan the individual, take the vital signs, check important chemical substances like electrolytes, hemoglobin, bicarbonates and other biomedical markers and come up with a diagnosis in a matter of minutes. The role of the doctor might then be to “discuss” with the machine about the rationale for making that diagnosis as well as explore other potential differentials. This goes a step ahead of the currently used clinical decision making systems in that the decisions might be made by the computer and doctors then help to serve as checks and balances.

2.     Patient Treatment: This means that almost no human contact will be needed to prescribe and dispense drugs for patients. The risk of wrong prescription or dispensing will be minimized and pharmacists will only need to monitor the computer programs, much as is being done in hospitals like Bumrungrad today. However, in the hospital of the future, the computer will send the drug prescription directly to the dispensing computer that will ensure that the drugs are given directly to the patient. This system could be expanded to involve medication adherence systems. I will discuss this in a later post.

3.     Streamlined electronic health records: in the health care system of the future, humans will have one unique medical record which they will have access to anytime, anywhere. This can be pulled up at accident scenes, operating theatres, outpatient facilities, etc. This personalized health record will be totally “virtual” and will carry a unique ID much like the social security number. It is personal to the patient and then, patient notes do not need to be carried about they are stored and retrievable but can be accessed remotely anytime

4.     Voice Recognition: There might be no need to write notes by the physician as systems of that day but the system will have automatic voice-recognition software. This will enable the doctor to save money and time because the computer will have the ability to write the notes for the doctor.

5.     Others: There are so many things that will change which cannot be foreseen at the moment but I think that most of it will be beneficial as it has been shown now. However it is important to remember that all innovations in technology might have unintended consequences and it is important to weave-in monitoring and evaluation as an important part of the utilization of new technologies.

Discussion on the Transformational Effect of IT on Health Care

The story of Oleg drives home the importance of quality in health care- which everyone seems to agree about. It also more importantly, stresses the value of information technology in helping to push the frontier of quality in the healthcare industry.

It is important to step away from the patients' point of view and focus instead; in this post on describing the various dimensions that quality in health care might take. It is a futuristic look at the various roles that health information technology might take in the hospital of the future, say 200 years from now.

The advantage of looking into the future is similar to the benefits derived from making sci-fi films which depict scenarios that might happen light years ahead of them. In an uncanny way, these movies seem to come to pass because they open up the imagination to think of the possibilities that might arise from new discoveries and these imaginations drive us to create the realities.

What will the hospital of the future look like? This question could be answered both regressively (looking backwards) and prospectively (looking forward). If that question were answered in the early 1800s, many people might not be able to predict so accurately, the role that information technology has played in our lives thus far. In the early 1800s with the prevalence of so many deadly communicable diseases like the plague or the black death, cholera, small pox and bacterial infections, surgery must have been very limited, however with the advent of the microscope many year later, we could see gems and Alexander Fleming discovered antibiotics. These discoveries changed the way we practice medicine and opened us up to brand new ways of providing healthcare.

I would like to postulate that on an even keel, one of the best discoveries to impact people’s health in this day and age is- you guessed it- the personal computer. With the advent of modern computing and the internet, technology has encroached in our lives in so many ways than we could ever predict. It has changed the way we manufacture, live, run our businesses and even interact with each other. After all, before these inventions, we would not be able to communicate in this way and we might not be able to share information as rapidly about the ever changing world of diseases and their management. So, what does the hospital of the future look like and what will health care look like many, many years from now? I will discuss that shortly.

A Patient's Perspective (2)- The Story of Oleg

Source: EnglishRussia.com

Oleg was born in the city of Omsk on a warm summer day in Russia twenty years ago. His parents were poor peasants who worked hard and saved some money to send their son to school. His dad worked in the lumber company in a nearby town while his mother taught in the local elementary school. He was the second child but his birth was celebrated with much pomp and pageantry in line with local customs, almost as though he were the first child. This is because he was born seven years after his elder brother. His naming ceremony was attended by almost everyone in the town and he was showered with gifts by so many well-wishers.

Oleg grew up with his mother and father doting over him, but at about the age of five years, he was sickly and was not allowed to play with the kids for fear of “catching a fever”. Everyone thought he was just spoiled silly, but his parents suspected something was wrong. They had gone to the local doctor so many times but he assured them that Oleg was fine and that he was only passing through this phase.

The Road from Omsk.
Source:omskcityblogspot

Then one cold December morning, Oleg complained of weakness of his limbs and for the entire day, could not move his legs or arms and was crying due to the excessive pain. Panic-stricken, the parents rushed him to the local doctor who was at a loss about what to do. The primary care doctor could only guess what this strange condition was- he had no way to test the child in order to make a diagnosis, he did not even have painkillers strong enough to stop the pain. He tried calling the hospital at the next town but there was nothing they could do- they had to try to bring the child to the hospital the next morning. At dawn, the parents and the family doctor set forth to go to the hospital, four hours away by road - the child cried all the way to the hospital.

At the local district hospital, the doctors succeeded in giving the child some very strong painkillers and he slept fitfully- for the first time in 2 days. Alas, the hospital did not have the necessary equipment to diagnose the condition and they had to refer to the specialist hospital in far away Moscow. Could they call the doctors over there so they could have a discussion about the case? Yes but the phone call was limited because the specialist could not see the patient- he could only rely on what the other doctors said.  Finally, they agreed to send the child to Moscow but the parents refused. They had no money. How could they fly their son to Moscow? How could they even afford his medical bills? There was simply no way. Sophia, Oleg’s mother wept bitterly.

Russian Specialist Hospital
Source:Indiabizclub

The people from the town took a collection for the family and they were finally able to send Oleg to Moscow for specialist care. The tests were done and the doctors argued bitterly over the possible diagnosis. Lou Gehrig’s disease? Amyotrophic lateral sclerosis? Guillain Barre’s syndrome? They finally had to make use of the hospital’s newly installed Clinical Decision Support System to make a final diagnosis in line with current evidence based research: Multiple Sclerosis.

The clinicians were glad that their multi-million ruble electronic medical record fitted with a state-of-the-art clinical decision support system was finally yielding dividends. However, the battle for Oleg’s life had just begun…

Patients' Perspective of IT and Quality of Care

A few of my readers have asked me to be slightly less “technical” in my writing as some of the material seemed too arcane for some readers who are non-medical or non-information technology savvy. In the light of this, I have decided to make this post a little less technical and address it to a broader audience.

What I will like to discuss this time, is essentially quality control and information technology from the perspective of a patient and not from the angle of the technicians or service providers. I want to make a case for the importance of the uptake of information technology in every sphere of the health care value chain. By this term, I mean the entire gamut of patient care from the time the patient gets sick to the time he/ she comes in contact with the service provider until the time he/she is discharged.  All the transactions that take place during this interaction are important and as we know, it affects the final outcome: basically whether the patient gets well completely, his/her condition is managed properly such that they can live comfortably with the complications or the patient gets worse (hopefully not) or dies (heaven forbid!).

Source: iStockPhoto

Every contact with care providers is thus important for the patient and also for the provider in many ways. Every patient is an opportunity for the medical personnel- nurses, doctors, pharmacists, physiotherapists, etc to learn about the case and get better- this is the idea behind teaching hospitals. In addition, every patient is a unique source of data. Even though this might sound strange to some readers, it is very true. From preventive health interventions to the first time the patient comes in, the patient supplies data- about time of entry, presenting complaint, diagnosis, drug interactions, drug efficacy, efficacy of medical interventions, infection control… the list is virtually endless. The data collected can then be utilized to improve medical processes and care for patients.

Despite these however, the average patient does not care for the various terminologies, but basically about this: “help me get well, with effective but inexpensive medical care that will help me have a better quality of life”. To the trained eye, the statement is very complicated as there is an entire range of arguable definitions like, how do you define “humane treatment”, “inexpensive”, “quality of life” etc. To the patient however, it is simple.

We will explore this through the hypothetical experiences of two patients in two different contexts: Oleg in Omsk, Russia and Sama in Bombay, India.

I will tell you their story in the next few posts.